IAOMT Comprehensive Review On Artificial Water Fluoridation

International Academy of Oral Medicine and Toxicology (IAOMT)
Comprehensive Review on Artificial Water Fluoridation

David Kennedy, DDS, MIAOMT
Amanda Just, MS, Program Director of the IAOMT
John Kall, DMD, FAGD, MIAOMT
Griffin Cole, DDS, NMD, MIAOMT
Originally Released on September 22, 2017
This document consists of excerpts taken from the document entitled “International Academy of Oral Medicine
and Toxicology (IAOMT) Position Paper against Fluoride Use in Water, Dental Materials, and Other Products
for Dental and Medical Practitioners, Dental and Medical Students, Consumers, and Policy Makers.”
Click here to access the full document.
TABLE OF CONTENTS
Section 1: Chemical Profile and Examples of Products with Added Fluoride, Page 2
Section 2: Sources of Fluoride in the Water, Page 2
Section 3: Brief History of Artificial Water Fluoridation, Pages 2-3
Section 4: Overview of U.S. Artificial Water Fluoridation Regulations, Pages 3-4
Section 5: Health Effects of Fluoride, Pages 5-9
Section 5.1: Skeletal, including Dental Fluorosis, Skeletal Fluorosis, Cancer of the Bone, Pages 5-6
Section 5.2: Central Nervous System, Pages 6-7
Section 5.3: Cardiovascular System, Page 7
Section 5.4: Endocrine System, Pages 7-8
Section 5.5: Renal System, Page 8
Section 5.6: Respiratory System, Page 8
Section 5.7: Digestive System, Pages 8-9
Section 5.8: Immune System, Page 9
Section 5.9: Integumentary System, Page 9
Section 6: Fluoride Exposure Levels, Pages 9-11
Section 6.1: Individualized Responses and Susceptible Subgroups, Pages 11-12
Section 6.2: Multiple Sources of Fluoride Exposure from Water and Food, Pages 12-13
Section 6.3: Interactions of Fluoride with Other Chemicals, Page 13
Section 7: Lack of Efficacy, Lack of Evidence, and Lack of Ethics, Pages 14-18
Section 8: Conclusion, Pages 18-19
Endnotes: Pages 19-30
Disclaimer: The IAOMT has used scientific evidence, expert opinion, and its professional judgment in assessing this information and
formulating this comprehensive review. No other warranty or representation, expressed or implied, as to the interpretation, analysis,
and/or efficacy of the information is intended in this document. The views expressed in this publication do not necessarily reflect the
views of the IAOMT’s Executive Council, Scientific Advisory Board, administration, membership, employees, contractors, etc. This
report is based solely on the information the IAOMT has obtained to date, and updates should be expected. Furthermore, as with all
guidelines, the potential for exceptions to the recommendations based upon individual findings and health history must likewise be
recognized. IAOMT disclaims any liability or responsibility to any person or party for any loss, damage, expense, fine, or penalty
which may arise or result from the use of any information or recommendations contained in this report. Any use which a third party
makes of this report, or any reliance on or decisions made based on it, are the sole responsibility of the third party.
International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 1

Section 1: Chemical Profile and Examples of Products with Added Fluoride
Fluorine (F) is the ninth element on the periodic table and is a member of the halogen family. Fluoride (F-) is a
chemical ion of fluorine that contains an extra electron, thereby giving it a negative charge. Other than its
natural existence in minerals, as well as in soil, water, and air, fluoride is also chemically synthesized for use in
community water fluoridation, dental products, and other manufactured items, as shown in Table 1.
Table 1: Examples of Products that May Contain Added Fluoride

Artificially fluoridated municipal water Beverages (made with fluoridated water)
Dental cements with fluoride Dental fillings with fluoride
Dental gels with fluoride Dental varnishes with fluoride
Floss with fluoride Fluoride drugs (“supplements”)
Food (that contains or has been exposed to fluoride) Mouthwash with fluoride
Pesticides with fluoride Pharmaceutical drugs with perfluorinated compounds
Stain resistant and waterproof items with PFCs Toothpaste with fluoride
Fluoride is not essential for human growth and development. 1 In fact, it is not required for any physiological
process in the human body; consequently, no one will suffer from a lack fluoride. In 2014, Dr. Philippe
Grandjean of the Harvard School of Public Health and Dr. Philip J. Landrigan of Icahn School of Medicine at
Mount Sinai identified fluoride as one of 12 industrial chemicals known to cause developmental neurotoxicity
in humans.2
Section 2: Sources of Fluoride in Water
Fluoride exposure in humans occurs from in water from both natural and anthropogenic sources. Natural
fluoride in water occurs when water run-off is exposed to fluoride containing rock. Because of this geological
factor, different regions have higher or lower levels of natural fluoride in water. Additional fluoride in water
occurs due to human activity through community water fluoridation, as well as through industrial emissions,
such as releases from coal-fired power plants.
Most of the fluoride added to drinking water is in the form of fluorosilicates, also known as fluosilicic acid
(fluorosilicic acid, H2SiF6) and sodium salt (sodium fluorosilicate, Na2SiF6).3 Although fluoride is added to
some bottled water, this comprehensive review focuses only on artificial water fluoridation.
Section 3: Brief History of Artificial Water Fluoridation
Human knowledge of the mineral fluorspar dates back centuries. 4 However, the discovery of how to isolate
fluorine from its compounds is an essential date in the history of humankind’s use of fluoride: Several scientists
were killed in early experiments involving attempts to generate elemental fluorine, but in 1886, Henri Moissan
reported the isolation of elemental fluorine, which earned him the Nobel Prize in chemistry in 1906. 5 6
This discovery paved the way for human experimentation to begin with chemically synthesized fluorine
compounds, which were eventually utilized in a number of industrial activities. Notably, uranium fluoride and
thorium fluoride were used during the years of 1942-1945 as part of the Manhattan Project 7 to produce the first
atomic bomb. Data from reports about the Manhattan Project, some of which were initially classified and
unpublished, include mention of fluoride poisoning and its role in the hazards of the uranium industry. 8 As
industry expanded during the 20th century, so did the use of fluoride for industrial processes, and cases of
fluoride poisoning likewise increased. 9

Fluoride was not widely used for any dental purposes prior to the mid-1940’s,10 although it was studied for
dental effects caused by its natural presence in community water supplies at varying levels. Early research in
the 1930’s by Frederick S. McKay, DDS, correlated high levels of fluoride with increased cases of dental
fluorosis (a permanent damage to the enamel of the teeth that can occur in children from overexposure to
fluoride) and demonstrated that reducing levels of fluoride resulted in lower rates of dental fluorosis. 11 12 This
work led H. Trendley Dean, DDS, to research fluoride’s minimal threshold of toxicity in the water supply. 13 In
work published in 1942, Dean suggested that lower levels of fluoride might result in lower rates of dental
caries.14
While Dean worked to convince others to test his hypothesis about adding fluoride to community water supplies
as a means of reducing caries, not everyone supported the idea. In fact, an editorial published in the Journal of
the American Dental Association (JADA) in 1944 denounced purposeful water fluoridation and warned of its
dangers:
We do know the use of drinking water containing as little as 1.2 to 3.0 parts per million of fluorine will
cause such developmental disturbances in bones as osteosclerosis, spondylosis, and osteopetrosis, as
well as goiter, and we cannot afford to run the risk of producing such serious systemic disturbances in
applying what is at present a doubtful procedure intended to prevent development of dental
disfigurements among children.
[…] Because of our anxiety to find some therapeutic procedure that will promote mass prevention of
caries, the seeming potentialities of fluorine appear speculatively attractive, but, in the light of our
present knowledge or lack of knowledge of the chemistry of the subject, the potentialities for harm far
outweigh those for good.15
A few months after this warning was issued, Grand Rapids, Michigan, became the first city to be artificially
fluoridated on January 25, 1945. Dean had succeeded in his efforts to test his hypothesis, and in a landmark
study, Grand Rapids was to serve as a test city, and its decay rates were to be compared with those of non-
fluoridated Muskegon, Michigan. After only slightly more than five years, Muskegon was dropped as a control
city, and the results published about the experiment only reported the decrease in caries in Grand Rapids. 16
Because the results did not include the control variable from the incomplete Muskegon data, many have stated
that the initial studies presented in favor of water fluoridation were not even valid.
Concerns were made to the United States Congress in 1952 about potential dangers of water fluoridation, the
lack of evidence as to its alleged usefulness in controlling dental caries, and the need for more research to be
conducted.17 Yet, in spite of these concerns and many others, experiments with fluoridated drinking water
continued. By 1960, fluoridation of drinking water for alleged dental benefits had spread to over 50 million
people in communities throughout the United States. 18
Section 4: Overview of U.S. Artificial Water Fluoridation Regulations
In western Europe, some governments have openly recognized hazards of fluoride, and only 3% of the western
European population drinks fluoridated water. 19 In the United States, over 66% of Americans are drinking
fluoridated water.20 Neither the Environmental Protection Agency (EPA) nor the federal government mandate
water fluoridation in America, and the decision to fluoridate community water is made by the state or local
municipality. 21 22 However, the U.S. Public Health Service (PHS) establishes recommended fluoride
concentrations in community drinking water for those who choose to fluoridate, and the Environmental
Protection Agency (EPA) sets contaminant levels for public drinking water.

After water fluoridation in Grand Rapids, Michigan, began in 1945, the practice spread to locales across the
country in the decades that followed. These efforts were encouraged by the Public Health Service (PHS) in the
1950s,23 and in 1962, the PHS issued standards for fluoride in drinking water that would stand for 50 years.
They stated that fluoride would prevent dental caries 24 and that optimal levels of fluoride added to drinking
water should range between 0.7 to 1.2 milligrams per liter. 25 However, the PHS lowered this recommendation
to the single level of 0.7 milligrams per liter in 2015 due to an increase in dental fluorosis (permanent damage
to the teeth that can occur in children from overexposure to fluoride) and due to the increase in sources of
fluoride exposure to Americans.26
Meanwhile, the Safe Drinking Water Act was established in 1974 to protect the quality of American drinking
water, and it authorized the EPA to regulate public drinking water. Because of this legislation, the EPA can set
enforceable maximum contaminant levels (MCLs) for drinking water, as well as non-enforceable maximum
contaminant level goals (MCLGs) and non-enforceable drinking water standards of secondary maximum
contaminant levels (SMCLs).27 The EPA specifies that the MCLG is “the maximum level of a contaminant in
drinking water at which no known or anticipated adverse effect on the health of persons would occur, allowing
an adequate margin of safety.”28 Additionally, the EPA qualifies that community water systems exceeding the
MCL for fluoride “must notify persons served by that system as soon as practical, but no later than 30 days after
the system learns of the violation.”29
In 1975, the EPA set a maximum contaminant level (MCL) for fluoride in drinking water at 1.4 to 2.4
milligrams per liter. 30 They established this limit to prevent cases of dental fluorosis. In 1981, South Carolina
argued that dental fluorosis is merely cosmetic, and the state petitioned the EPA to eliminate the MCL for
fluoride. 31 As a result, in 1985, the EPA established a maximum contaminant level goal (MCLG) for fluoride at
4 milligrams per liter.32 Rather than dental fluorosis serving as the protective endpoint (which would have
required lower safety levels), this higher level was established as a means to protect against skeletal fluorosis, a
bone disease caused by excess fluoride. Using skeletal fluorosis as the endpoint likewise resulted in a change
for the MCL for fluoride, which was raised to 4 milligrams per liter in 1986. 33 Yet, dental fluorosis was applied
as the endpoint for the SMCL for fluoride of 2 milligrams per liter, which was also set in 1986. 34
Controversy ensued over these new regulations and even resulted in legal actions against the EPA. South
Carolina argued that there was no need for any MCLG (maximum contaminant level goal) for fluoride, while
the Natural Resources Defense Council argued that the MCLG should be lowered based on dental fluorosis. 35 A
court ruled in the EPA’s favor, but in a review of fluoride standards, the EPA enlisted the National Research
Council (NRC) of the National Academy of Sciences to re-evaluate the health risks of fluoride.36 37
The report from the National Research Council, released in 2006, concluded that the EPA’s MCLG (maximum
contaminant level goal) for fluoride should be lowered. 38 In addition to recognizing the potential for risk of
fluoride and osteosarcoma (a bone cancer), the 2006 National Research Council report cited concerns about
musculoskeletal effects, reproductive and developmental effects, neurotoxicity and neurobehavioral effects,
genotoxicity and carcinogenicity, and effects on other organ systems. 39
The NRC concluded that the MCLG for fluoride should be lowered in 2006, but the EPA has yet to lower the
level. 40 In 2016, the Fluoride Action Network, the IAOMT, and a number of other groups and individuals
petitioned the EPA to protect the public, especially susceptible subpopulations, from the neurotoxic risks of
fluoride by banning the purposeful addition of fluoride to drinking water. 41 The petition was denied by the EPA
in February 2017. 42

Section 5: Health Effects of Fluoride
Since the NRC report was released in 2006, a number of other relevant research studies have been published.
The discussion below includes a synopsis of some of the major research included in the 2006 NRC report, as
well as some of the research of interest that has been published since that time.
Section 5.1: Skeletal System
Fluoride taken into the human body enters the bloodstream through the digestive tract. 43 Most of the fluoride
that is not released through urine is stored in the body. It is generally stated that 99% of this fluoride resides in
the bone,44 where it is incorporated into the crystalline structure and accumulates over time. 45 Thus, it is
indisputable that the teeth and bones are tissues of the body that concentrate the fluoride to which we are
exposed.
In fact, in its 2006 report, the National Research Council (NRC)’s discussion on the danger of bone fractures
from excessive fluoride was substantiated with significant research. Specifically, the report stated: “Overall,
there was consensus among the committee that there is scientific evidence that under certain conditions fluoride
can weaken bone and increase the risk of fractures.”46
Section 5.1.1: Dental Fluorosis
Exposure to excess fluoride in children is known to result in dental fluorosis, a condition in which the teeth
enamel becomes irreversibly damaged and the teeth become permanently discolored, displaying a white or
brown mottling pattern and forming brittle teeth that break and stain easily. 47 It has been scientifically
recognized since the 1940’s that overexposure to fluoride causes this condition, which can range from very mild
to severe. According to data from the Centers for Disease Control and Prevention (CDC) released in 2010, 23%
of Americans aged 6-49 and 41% of children aged 12-15 exhibit fluorosis to some degree.48 These drastic
increases in rates of dental fluorosis were a crucial factor in the Public Health Service’s decision to lower its
water fluoridation level recommendations in 2015. 49
Figure 1: Dental Fluorosis Ranging

from Very Mild to Severe
(Photos from Dr. David Kennedy and
used with permission from victims of
dental fluorosis.)
Section 5.1.2: Skeletal Fluorosis and Arthritis
Like dental fluorosis, skeletal fluorosis is an undeniable effect of overexposure to fluoride. Skeletal fluorosis
causes denser bones, joint pain, a limited range of joint movement, and in severe cases, a completely rigid
spine.50 Although considered rare in the U.S., the condition does occur,51 and it has been recently suggested
that skeletal fluorosis could be more of a public health issue than previously recognized. 52
As research published in 2016 noted, there is not yet a scientific consensus as to how much fluoride and/or how
long levels of fluoride need to be taken in before skeletal fluorosis occurs.53 While some authorities have
suggested skeletal fluorosis only occurs after 10 years or more of exposure, research has shown that children
can develop the disease in as little as six months, 54 and some adults have developed it in as little as two to seven
years. 55 Similarly, while some authorities have suggested that 10 mg/day of fluoride is necessary to develop
skeletal fluorosis, research has reported that much lower levels of exposure to fluoride (in some cases less than
2ppm) can also cause the disease. 56 Furthermore, research published in 2010 confirmed that skeletal tissue
response to fluoride varies by individual. 57
In patients with skeletal fluorosis, fluoride has also been suspected of causing secondary hyperparathyroidism
and/or causing bone damage resembling secondary hyperparathyroidism. The condition, which commonly
results from kidney disease, is triggered when the levels of calcium and phosphorous in the blood are too low. 58
A number of studies that have been collected by the Fluoride Action Network (FAN) examine the possibility
that fluoride is one contributor to this health effect.59
Because arthritic symptoms are associated with skeletal fluorosis, arthritis is another area of concern in relation
to fluoride exposures. Notably in this regard, research has linked fluoride to osteoarthritis, both with or without
skeletal fluorosis. 60 Additionally, temporomandibular joint disorder (TMJ) has been associated with dental and
skeletal fluorosis. 61
Section 5.1.3: Cancer of the Bone, Osteosarcoma
In 2006, the NRC discussed a potential link between fluoride exposure and osteosarcoma. This type of bone
cancer has been recognized as “the sixth most common group of malignant tumors in children and the third
most common malignant tumor for adolescents.”62 The NRC stated that while evidence was tentative, fluoride
appeared to have the potential to promote cancers. 63 They elucidated that osteosarcoma was of significant
concern, especially because of fluoride deposition in bone and the mitogenic effect of fluoride on bone cells. 64
While some studies have failed to find an association between fluoride and osteosarcoma, according to the
research completed by Dr. Elise Bassin while at Harvard School of Dental Medicine, exposure to fluoride at
recommended levels correlated with a seven-fold increase in osteosarcoma when boys were exposed between
the ages of five and seven.65 Bassin’s research, published in 2006, is the only study about osteosarcoma that has
taken age-specific risks into account.66
Section 5.2: Central Nervous System
The potential for fluorides to impact the brain have been well-established. In their 2006 report, the NRC
explained: “On the basis of information largely derived from histological, chemical, and molecular studies, it is
apparent that fluorides have the ability to interfere with the functions of the brain and the body by direct and
indirect means.”67 Both dementia and Alzheimer’s disease are also mentioned in the NRC report for
consideration as being potentially linked to fluoride. 68
These concerns have been substantiated. Studies about water fluoridation and IQ effects were closely examined
in research published in October of 2012 in Environmental Health Perspectives.69 In this meta-review, 12
studies demonstrated that communities with fluoridated water levels below 4 mg/L (average of 2.4 mg/L) had
lower IQs than the control groups.70 Since the publication of the 2012 review, a number of additional studies
finding reduced IQs in communities with less than 4 mg/L of fluoride in the water have become available. 71 To
be more precise, in a citizen petition to the EPA in 2016, Michael Connett, Esq., Legal Director of FAN,
identified 23 studies reporting reduced IQ in areas with fluoride levels currently accepted as safe by the EPA. 72
Moreover, in 2014, a review was published in The Lancet entitled “Neurobehavioral effects of developmental
toxicity.” In this review, fluoride was listed as one of 12 industrial chemicals known to cause developmental
neurotoxicity in human beings.73 The researchers warned: “Neurodevelopmental disabilities, including autism,
attention-deficit hyperactivity disorder, dyslexia, and other cognitive impairments, affect millions of children
worldwide, and some diagnoses seem to be increasing in frequency. Industrial chemicals that injure the
developing brain are among the known causes for this rise in prevalence.” 74
Section 5.3: Cardiovascular System
According to statistics published in 2016, heart disease is the leading cause of death for both men and women in
the U.S., and it costs the country $207 billion annually. 75 Thus, recognizing the potential relationship between
fluoride and cardiovascular problems is essential not only for safe measures to be established for fluoride but
also for preventative measures to be established for heart disease.
An association between fluoride and cardiovascular problems has been suspected for decades. The 2006 NRC
report described a study from 1981 by Hanhijärvi and Penttilä that reported elevated serum fluoride in patients
with cardiac failure.76 Fluoride has also been related to arterial calcification, 77 arteriosclerosis,78 cardiac
insufficiency, 79 electrocardiogram abnormalities, 80 hypertension, 81 and myocardial damage.82 Additionally,
researchers of a study from China published in 2015 concluded: “The results showed that, NaF [sodium
fluoride], in a concentration dependent-manner and even at the low concentration of 2 mg/L, changed the
morphology of the cardiomyocytes, reduced cell viability, increased the cardiac arrest rate, and enhanced the
levels of apoptosis.”83
Section 5.4: Endocrine System
Fluoride’s effects on the endocrine system, which consists of glands that regulate hormones, have also been
studied. In the 2006 NRC report, it was stated: “In summary, evidence of several types indicates that fluoride
affects normal endocrine function or response; the effects of the fluoride-induced changes vary in degree and
kind in different individuals.” 84 The 2006 NRC report further included a table demonstrating how extremely
low doses of fluoride have been found to disrupt thyroid function, especially when there was a deficiency in
iodine present.85 In more recent years, the impact of fluoride on the endocrine system has been re-emphasized.
A study published in 2012 included sodium fluoride on a list of endocrine disrupting chemicals (EDCs) with
low-dose effects,86 and the study was cited in a 2013 report from the United Nations Environment Programme
and the World Health Organization. 87
Meanwhile, increased rates of thyroid dysfunction have been associated with fluoride. 88 Research published in
2015 by researchers at the University of Kent in Canterbury, England, noted that higher levels of fluoride in
drinking water could predict higher levels of hypothyroidism. 89 They further explained: “In many areas of the
world, hypothyroidism is a major health concern and in addition to other factors—such as iodine deficiency—
fluoride exposure should be considered as a contributing factor. The findings of the study raise particular
concerns about the validity of community fluoridation as a safe public health measure.” 90 Other studies have
supported the association between fluoride and hypothyroidism, 91 an increase in thyroid stimulating hormone
(THS),92 and iodine deficiency. 93
According to statistics released by the Centers for Disease Control and Prevention (CDC) in 2014, 29.1 million
people or 9.3% of the population have diabetes. 94 Again, the potential role of fluoride in this condition is
essential to consider. The 2006 NRC report warned:
The conclusion from the available studies is that sufficient fluoride exposure appears to bring about
increases in blood glucose or impaired glucose tolerance in some individuals and to increase the severity
of some types of diabetes. In general, impaired glucose metabolism appears to be associated with serum

or plasma fluoride concentrations of about 0.1 mg/L or greater in both animals and humans (Rigalli et al.
1990, 1995; Trivedi et al. 1993; de al Sota et al. 1997).95
Research has also associated diabetes with a reduced capacity to clear fluoride from the body, 96 as well as a
syndrome (polydispsia-polyurea) that results in increased intake of fluoride, 97 and research has also linked
insulin inhibition and resistance to fluoride. 98
Also of concern is that fluoride appears to interfere with functions of the pineal gland, which helps control
circadian rhythms and hormones, including the regulation of melatonin and reproductive hormones. Jennifer
Luke of the Royal Hospital of London has identified high levels of fluoride accumulated in the pineal gland 99
and further demonstrated that these levels could reach up to 21,000 ppm, rendering them higher than the
fluoride levels in the bone or teeth.100 Other studies have linked fluoride to melatonin levels, 101 insomnia,102
and early puberty in girls, 103 as well as lower fertility rates (including men) and reduced testosterone levels. 104
Section 5.5: Renal System
Urine is a major route of excretion for fluoride taken into the body, and the renal system is essential for the
regulation of fluoride levels in the body. 105 106 Urinary excretion of fluoride is influenced by urine pH, diet,
presence of drugs, and other factors.107 Researchers of a 2015 article published by the Royal Society of
Chemistry explained: “Thus, plasma and the kidney excretion rate constitutes the physiologic balance
determined by fluoride intake, uptake to and removal from bone and the capacity of fluoride clearance by the
kidney.”108
The 2006 NRC report likewise recognized the role of the kidney in fluoride exposures. They noted that it is not
surprising for patients with kidney disease to have increased plasma and bone fluoride concentrations. 109 They
further stated that human kidneys “have to concentrate fluoride as much as 50-fold from plasma to urine.
Portions of the renal system may therefore be at higher risk of fluoride toxicity than most soft tissues.” 110
In light of this information, it makes sense that researchers have indeed linked fluoride exposures to problems
with the renal system. More specifically, researchers from Toronto, Canada, demonstrated that dialysis patients
with renal osteodystrophy had high levels of fluoride in the bone and concluded that “bone fluoride may
diminish bone microhardness by interfering with mineralization.” 111
Section 5.6: Respiratory System
The effects of fluoride on the respiratory system are most clearly documented in literature about occupational
exposures. Strictly from an occupational standpoint, the aluminum industry has been the subject of an array of
investigations into fluoride’s impact on the respiratory systems of workers. Evidence from a series of studies
indicates a correlation between workers at aluminum plants, exposures to fluoride, and respiratory effects, such
as emphysema, bronchitis, and diminished lung function. 112
Section 5.7: Digestive System
Upon ingestion, including through fluoridated water, fluoride is absorbed by the gastrointestinal system where it
has a half-life of 30 minutes.113 The amount of fluoride absorbed is dependent upon calcium levels, with higher
concentrations of calcium lowering gastrointestinal absorption. 114 115 Also, according to research published in
2015 by the American Institute of Chemical Engineers, fluoride’s interaction in the gastrointestinal system
“results in formation of hydrofluoric [HF] acid by reacting with hydrochloric [HCL] acid present in the
stomach. Being highly corrosive, the HF acid so formed will destroy the stomach and intestinal lining with the
loss of microvilli.”116
Other areas of the digestive system are also known to be impacted by fluoride. For example, the 2006 NRC
report called for more information about fluoride’s effect on the liver: “It is possible that a lifetime ingestion of
5-10 mg/day from drinking water containing fluoride at 4 mg/L might turn out to have long-term effects on the
liver, and this should be investigated in future epidemiologic studies.” 117
Section 5.8: Immune System
The immune system is yet another part of the body that can be impacted by fluoride. An essential consideration
is that immune cells develop in the bone marrow, so the effect of fluoride on the immune system could be
related to fluoride’s prevalence in the skeletal system. The 2006 NRC report elaborated on this scenario:
Nevertheless, patients who live in either an artificially fluoridated community or a community where the
drinking water naturally contains fluoride at 4 mg/L have all accumulated fluoride in their skeletal
systems and potentially have very high fluoride concentrations in their bones. The bone marrow is where
immune cells develop and that could affect humoral immunity and the production of antibodies to
foreign chemicals. 118
Allergies and hypersensitivities to fluoride are another risk component related to the immune system. Research
published in 1950’s, 1960’s, and 1970’s showed that some people are hypersensitive to fluoride. 119 120 More
recent studies have confirmed this reality. 121
Section 5.9: Integumentary System
Fluoride can also impact the integumentary system, which consists of the skin, exocrine glands, hair, and nails.
In particular, reactions to fluoride have been linked to acne and other dermatological conditions. 122 123 124 125
Additionally, hair and nails have been studied as biomarkers of fluoride exposure. 126 Nail clippings are capable
of demonstrating chronic fluoride exposures,127 and using fluoride concentrations in nails to identify children at
risk for dental fluorosis has been examined. 128
Section 6: Fluoride Exposure Levels
Due to increased rates of dental fluorosis and increased sources of exposure to fluoride, the Public Health
Service (PHS) lowered its recommended levels of fluoride set at 0.7 to 1.2 milligrams per liter in 1962129 to 0.7
milligrams per liter in 2015.130 The need to update previously established fluoride levels is extremely urgent, as
fluoride exposures have obviously surged for Americans since the 1940’s, when community water fluoridation
was first introduced.
Generally, the optimal exposure for fluoride has been defined as between 0.05 and 0.07 mg of fluoride per
kilogram of body weight.131 However, this level has been criticized for failing to directly assess how intake of
fluoride is related to the occurrence or severity of dental caries and/or dental fluorosis. 132 To elaborate, in a
2009 longitudinal study, researchers at the University of Iowa noted the lack of scientific evidence for this
intake level and concluded: “Given the overlap among caries/fluorosis groups in mean fluoride intake and
extreme variability in individual fluoride intakes, firmly recommending an ‘optimal’ fluoride intake is
problematic.”133
In light of this disparity, as well as the fact that the established levels directly influence the amounts of fluoride
to which consumers are exposed, it is essential to evaluate some of the established limits and recommendations
for fluoride exposures. While a description of fluoride regulations is provided in Section 4 of this document,
recommendations issued by other government groups are also important to consider. Comparing regulations
and recommendations helps to exemplify the complexity of establishing levels, of enforcing levels, of utilizing
them to protect all individuals, and of applying them to everyday life. To illustrate this point, Table 2 provides a
comparison of recommendations from the Public Health Service (PHS), recommendations from the Institute of
Medicine (IOM), and regulations from the Environmental Protection Agency (EPA).
Table 2: Comparison of PHS Recommendations, IOM Recommendations, and EPA Regulations for Fluoride
Intake
TYPE OF SPECIFIC FLUORIDE SOURCE OF
FLUORIDE LEVEL RECOMMENDATION/ INFORMATION AND NOTES
REGULATION
Recommendation for 0.7 mg per liter U.S. Public Health Service
Fluoride (PHS)134
Concentration in
Drinking Water for the This is a non-enforceable
Prevention of Dental recommendation.
Caries
Dietary Reference Infants 0-6 mo. 0.7 mg/d Food and Nutrition Board,
Intake: Infants 6-12 mo. 0.9 mg/d Institute of Medicine (IOM),
Tolerable Upper Children 1-3 y 1.3 mg/d National Academies135
Intake Level of Children 4-8 y 2.2 mg/d
Fluoride Males 9->70 y 10 mg/d This is a non-enforceable
Females 9->70 y* 10 mg/d recommendation.
(*includes pregnancy and lactation)
Dietary Reference Infants 0-6 mo. 0.01 mg/d Food and Nutrition Board,
Intake: Infants 6-12 mo. 0.5 mg/d Institute of Medicine (IOM),
Recommended Children 1-3 y 0.7 mg/d National Academies136
Dietary Allowances Children 4-8 y 1.0 mg/d
and Adequate Intakes Males 9-13 y 2.0 mg/d This is a non-enforceable
Males 14-18 y 3.0 mg/d recommendation.
Males 19->70 y 4.0 mg/d
Females 9-13 y 2.0 mg/d
Females 14->70 y* 3.0 mg/d
(*includes pregnancy and lactation)
Maximum 4.0 mg per liter U.S. Environmental Protection
Contaminant Level Agency (EPA) 137
(MCL) of Fluoride
from Public Water This is an enforceable
Systems regulation.
Maximum 4.0 mg per liter U.S. Environmental Protection
Contaminant Level Agency (EPA)138
Goal (MCLG) of
Fluoride from Public This is a non-enforceable
Water Systems regulation.
Secondary Standard of 2.0 mg per liter U.S. Environmental Protection
Maximum Agency (EPA) 139
Contaminant Levels
(SMCL) of Fluoride This is a non-enforceable
from Public Water regulation.
Systems

By interpreting these selected examples, it is obvious that the limits and recommendations for fluoride in food
and water vary tremendously and, in their current state, would be nearly impossible for consumers to
incorporate into daily life. It is also obvious that these levels do not consider a multitude of other fluoride
exposures. This means that consumers are reliant upon policy makers to protect them by enacting enforceable
regulations based upon accurate data. One issue is that accurate data does not exist for either collective sources
or singular sources of fluoride exposure. Another issue is that fluoride is known to impact each individual
differently.
Section 6.1: Individualized Responses and Susceptible Subgroups
Setting one universal level of fluoride as a recommended limit is also problematic because it does not take
individualized responses into account. While age, weight, and gender are sometimes considered in
recommendations, the current EPA regulations for water prescribe one level that applies to everyone, regardless
of infants and children and their known susceptibilities to fluoride exposures. Such a “one dose fits all” level
also fails to address allergies to fluoride, 140 genetic factors,141 142 143 nutrient deficiencies, 144 and other
personalized factors known to be pertinent to fluoride exposures.
The NRC recognized such individualized responses to fluoride numerous times in their 2006 publication,145 and
other research has affirmed this reality. For example, urine pH, diet, presence of drugs, and other factors have
been identified as relative to the amount of fluoride excreted in the urine. 146 As another example, fluoride
exposures of non-nursing infants were estimated to be 2.8-3.4 times that of adults.147 The NRC further
established that certain subgroups have water intakes that greatly vary from any type of assumed average levels:
These subgroups include people with high activity levels (e.g., athletes, workers with physically
demanding duties, military personnel); people living in very hot or dry climates, especially outdoor
workers; pregnant or lactating women; and people with health conditions that affect water intake. Such
health conditions include diabetes mellitus, especially if untreated or poorly controlled; disorders of
water and sodium metabolism, such as diabetes insipidus; renal problems resulting in reduced clearance
of fluoride; and short-term conditions requiring rapid rehydration, such as gastrointestinal upsets or food
poisoning. 148
Considering that the rate of diabetes is on the rise in the U.S., with over 9% (29 million) Americans
impacted,149 this particular subgroup is especially essential to factor into account. Furthermore, when added to
the other subgroups mentioned in the NRC report above (including infants and children), it is apparent that
hundreds of millions of Americans are at risk from the current levels of fluoride added to community drinking
water.
The American Dental Association (ADA), a trade-based group that promotes water fluoridation, 150 has also
recognized the issue of individual variance in fluoride intake. They have recommended for research to be
conducted to “[i]dentify biomarkers (that is, distinct biological indicators) as an alternative to direct fluoride
intake measurement to allow the clinician to estimate a person’s fluoride intake and the amount of fluoride in
the body.”151
Additional comments from the ADA provide even more insight into individualized responses related to fluoride
intake. The ADA has recommended to “[c]onduct metabolic studies of fluoride to determine the influence of
environmental, physiological and pathological conditions on the pharmacokinetics, balance and effects of
fluoride.”152 Perhaps most notably, the ADA has also acknowledged the susceptible subgroup of infants. In
regard to infant exposure from fluoridated water used in baby formula, the ADA recommends following the
American Academy of Pediatrics guideline that breastfeeding should be exclusively practiced until the child is
six months old and continued until 12 months, unless contraindicated.153
While suggesting to exclusively breastfeed infants is certainly protective of their fluoride exposures, it is simply
not practical for many American women today. The authors of a study published in 2008 in Pediatrics reported
that only 50% of women continued to breast feed at six months and only 24% of women continued to breast
feed at 12 months.154
What these statistics mean is that, due to infant formula mixed with fluoridated water, millions of infants most
certainly exceed the optimal intake levels of fluoride based on their low weight, small size, and developing
body. Hardy Limeback, PhD, DDS, a member of a 2006 National Research Council (NRC) panel on fluoride
toxicity, and former President of the Canadian Association of Dental Research, has elaborated: “Newborn
babies have undeveloped brains, and exposure to fluoride, a suspected neurotoxin, should be avoided.”155
Section 6.2: Multiple Sources of Fluoride Exposure from Water and Food
Fluoridated water, including its direct consumption and its use in other beverages and food preparation, is
generally considered the main source of fluoride exposure for Americans. The U.S. Public Health Service
(PHS) has estimated that the average dietary intake (including water) of fluoride for adults living in areas with
1.0 mg/L fluoride in the water as between 1.4 to 3.4 mg/day (0.02-0.048 mg/kg/day) and for children in
fluoridated areas as between 0.03 to 0.06 mg/kg/day. 156 Additionally, the Centers for Disease Control and
Prevention (CDC) has reported that water and processed beverages can comprise 75% of a person’s fluoride
intake. 157
The 2006 NRC report came to similar conclusions. The authors estimated just how much of overall fluoride
exposures are attributable to water when compared to pesticides/air, background food, and toothpaste, and they
wrote: “Assuming that all drinking-water sources (tap and non-tap) contain the same fluoride concentration and
using the EPA default drinking-water intake rates, the drinking-water contribution is 67-92% at 1 mg/L, 80-
96% at 2 mg/L, and 89-98% at 4 mg/L.”158 Yet, the levels of NRC’s estimated fluoridated water intake rates
were higher for athletes, workers, and individuals with diabetes. 159
It is important to reiterate that the fluoride added to water is not only taken in through drinking tap water. The
water is also used for growing crops, tending to livestock (and domestic pets), food preparation, and bathing. It
is also used to create other beverages, and for this reason, significant levels of fluoride have been recorded in
infant formula and commercial beverages, such as juice and soft drinks. 160 Significant levels of fluoride have
also been recorded in alcoholic beverages, especially wine and beer. 161 162
In the exposure estimates provided in the 2006 NRC report, fluoride in food consistently ranked as the second
largest source behind water.163 Increased levels of fluoride in food can occur due to human activity, especially
through food preparation and the use of pesticides and fertilizers. 164 Significant fluoride levels have been
recorded in grapes and grape products. 165 Fluoride levels have also been reported in cow’s milk due to
livestock raised on fluoride-containing water, feed, and soil, 166 as well as processed chicken167 (likely due to
mechanical deboning, which leaves skin and bone particles in the meat.)168
An essential question about these levels of fluoride intake is just how much is harmful. A study about water
fluoridation published in 2016 by Kyle Fluegge, PhD, of Case Western University, was conducted at the county
level in 22 states from 2005-2010. Dr. Fluegge reported that his findings suggested that “a 1 mg increase in the
county mean added fluoride significantly positively predicts a 0.23 per 1,000 person increase in age-adjusted
diabetes incidence (P < 0.001) and a 0.17% increase in age-adjusted diabetes prevalence percent (P < 0.001).”169
This led him to reasonably conclude that community water fluoridation is associated with epidemiological
outcomes for diabetes.

Other studies have produced equally concerning results. A study published in 2011 found that children with
0.05 to 0.08 mg/L of fluoride in their serum had a 4.2 drop in IQ when compared to other children. 170
Meanwhile, a study published in 2015 found that IQ points dropped at urinary fluoride levels between 0.7 and
1.5 mg/L, 171 and another study published in 2015 linked fluoride at levels >0.7 mg/L with hyperthyroidism. 172
Additional research has established the threat of health effects of fluoride in the water at levels currently
considered as safe.173
Section 6.3: Interactions of Fluoride with Other Chemicals
The concept of multiple chemicals interacting within the human body to produce ill-health should now be an
essential understanding required for practicing modern-day medicine. Researchers Jack Schubert, E. Joan
Riley, and Sylvanus A. Tyler addressed this highly relevant aspect of toxic substances in a scientific article
published in 1978. Considering the prevalence of chemical exposures, they noted: “Hence, it is necessary to
know the possible adverse effects of two or more agents in order to evaluate potential occupational and
environmental hazards and to set permissible levels.”174
The need to study the health outcomes caused by exposures to a variety of chemicals has also been reported by
researchers affiliated with a database which tracks associations between approximately 180 human diseases or
conditions and chemical contaminants. Supported by the Collaborative on Health and the Environment, the
researchers for this project, Sarah Janssen, MD, PhD, MPH, Gina Solomon, MD, MPH, and Ted Schettler, MD,
MPH, clarified:
More than 80,000 chemicals have been developed, distributed, and discarded into the environment over
the past 50 years. The majority of them have not been tested for potential toxic effects in humans or
animals. Some of these chemicals are commonly found in air, water, food, homes, work places, and
communities. Whereas the toxicity of one chemical may be incompletely understood, an understanding
of the effect from exposures to mixtures of chemicals is even less complete. 175
Clearly, the interaction of fluoride with other chemicals is crucial to understanding exposure levels and their
impacts. While countless interactions have yet to be examined, several hazardous combinations have been
established.
Aluminofluoride exposure occurs from ingesting a fluoride source with an aluminum source.176 This synergistic
exposure to fluoride and aluminum can occur through water, tea, food residue, infant formulas, aluminum-
containing antacids or medications, deodorants, cosmetics, and glassware. 177 Authors of a research report
published in 1999 described the hazardous synergy between these two chemicals: “In view of the ubiquity of
phosphate in cell metabolism and together with the dramatic increase in the amount of reactive aluminum now
found in ecosystems, aluminofluoride complexes represent a strong potential danger for living organisms
including humans.”178
Furthermore, fluoride, in its form of hydrofluosilicic acid (which is added to many water supplies to fluoridate
the water), attracts manganese and lead (both of which can be present in certain types of plumbing pipes).
Likely because of the affinity for lead, fluoride has been linked to higher blood lead levels in children, 179
especially in minority groups.180 Lead is known to lower IQs in children, 181 and lead has even been linked to
violent behavior.182 183 Other research supports the potential association of fluoride with violence. 184

Section 7: Lack of Efficacy, Lack of Evidence, and Lack of Ethics
Section 7.1: Lack of Efficacy
The fluoride in many products is added because it allegedly reduces dental caries. The suggested benefits of
this form of fluoride are related to its activity on teeth of inhibiting bacterial respiration of Streptococcus
mutans, the bacterium that turns sugar and starches into a sticky acid that dissolves enamel. 185 In particular, the
interaction of fluoride with the mineral component of teeth produces a fluorohydroxyapatite (FHAP or FAP),
and the result of this action is said to be enhanced remineralization and reduced demineralization of the teeth.
While there is scientific support for this mechanism of fluoride, it has also been established that fluoride
primarily works to reduce tooth decay topically (i.e. scrubbing it directly onto to teeth with a toothbrush), as
opposed to systemically (i.e. drinking or ingesting fluoride through water or other means). 186
Although the topical benefits of fluoride have been distinctly expressed in scientific literature, research has
likewise questioned these benefits. For example, researchers from the University of Massachusetts Lowell
explained several controversies associated with topical uses of fluoride in an article published in the Journal of
Evidence-Based Dental Practice in 2006. After citing a 1989 study from the National Institute of Dental
Research that found minimal differences in children receiving fluoride and those not receiving fluoride, the
authors referenced other studies demonstrating that cavity rates in industrialized countries have decreased
without fluoride use.187 The authors further referenced studies indicating that fluoride does not aid in
preventing pit and fissure decay (which is the most prevalent form of tooth decay in the U.S.) or in preventing
baby bottle tooth decay (which is prevalent in poor communities).188
As another example, early research used to support water fluoridation as a means of reducing dental caries was
later re-examined, and the potential of misleading data was identified. Initially, the reduction of decayed and
filled deciduous teeth (DFT) collected in research was interpreted as proof for the efficacy of water fluoridation.
However, subsequent research by Dr. John A. Yiamouyiannis suggested that water fluoridation could have
contributed to the delayed eruption of teeth. 189 Such delayed eruption would result in less teeth and therefore,
the absence of decay, meaning that the lower rates of DFT were actually caused by the lack of teeth as opposed
to the alleged effects of fluoride on dental caries.
Other examples in the scientific literature have questioned fluoride’s use in preventing tooth decay. A 2014
review affirmed that fluoride’s anti-caries effect is reliant upon calcium and magnesium in the tooth enamel but
also that the remineralization process in tooth enamel is not dependent on fluoride. 190 Research published in
2010 identified that the concept of “fluoride strengthening teeth” could no longer be deemed as clinically
significant to any decrease in caries linked to fluoride use. 191 Furthermore, research has suggested that systemic
fluoride exposure has minimal (if any) effect on the teeth,192 193 and researchers have also offered data that
dental fluorosis (the first sign of fluoride toxicity 194) is higher in U.S. communities with fluoridated water as
opposed to those without it.195
Still other reports show that as countries were developing, decay rates in the general population rose to a peak
of four to eight decayed, missing, or filled teeth (in the 1960’s) and then showed a dramatic decrease (to today’s
levels), regardless of fluoride use. It has been hypothesized that increased oral hygiene, access to preventative
services, and more awareness of the detrimental effects of sugar are responsible for the visible decrease of tooth
decay. Whatever the reasons might be, it should be noted that this trend of decreased tooth decay occurred with
and without the systemic application of fluoridated water,196 so it would appear that factors other than fluoride
caused this change. Figure 2 below exhibits the tooth decay trends by fluoridated and non-fluoridated countries
from 1955-2005.

Figure 2: Tooth Decay Trends in Fluoridated and Unfluoridated Countries, 1955-2005
Several other considerations are relevant in any decision about using fluoride to prevent caries. First, it should
also be noted that fluoride is not an essential component for human growth and development. 197 Second,
fluoride has been recognized as one of 12 chemicals “known to cause developmental neurotoxicity in human
beings.”198 And finally, the American Dental Association (ADA) called for more research in 2013 in regard to
the mechanism of fluoride action and effects:
Research is needed regarding various topical fluorides to determine their mechanism of action and
caries-preventive effects when in use at the current level of background fluoride exposure (that is,
fluoridated water and fluoride toothpaste) in the United States. Studies regarding strategies for using
fluoride to induce arrest or reversal of caries progression, as well as topical fluoride's specific effect on
erupting teeth, also are needed.199
Section 7.2: Lack of Evidence
References to the unpredictability of levels at which fluoride’s effects on the human system occur have been
made throughout this position paper. However, it is important to reiterate the lack of evidence associated with
fluoride usage, and thus, Table 3 provides an abbreviated list of stringent warnings from governmental,
scientific, and other pertinent authorities about the dangers and uncertainties related to utilizing artificially
fluoridated water.
Table 3: Selected Quotes about Fluoride Warnings Categorized by Product/Process and Source
PRODUCT/ QUOTE/S SOURCE OF INFORMATION
PROCESS
REFERENCED
Water “Fluoride exposure has a complex Peckham S, Awofeso N. Water
fluoridation relationship in relation to dental caries fluoridation: a critical review of
and may increase dental caries risk in the physiological effects of
malnourished children due to calcium ingested fluoride as a public
depletion and enamel hypoplasia...” health intervention. The
Scientific World Journal. 2014
Feb 26; 2014.
Fluoride for “The prevalence of dental caries in a Centers for Disease Control and
dental uses, population is not inversely related to Prevention (CDC). Kohn WG,
including water the concentration of fluoride in enamel, Maas WR, Malvitz DM, Presson
fluoridation and a higher concentration of enamel SM, Shaddik KK.
fluoride is not necessarily more Recommendations for using
efficacious in preventing dental caries.” fluoride to prevent and control
dental caries in the United
“Few studies evaluating the States. Morbidity and Mortality
effectiveness of fluoride toothpaste, gel, Weekly Report:
rinse, and varnish among adult Recommendations and Reports.
populations are available.” 2001 Aug 17:i-42.
Fluoride in “Overall, there was consensus among National Research Council.

drinking water the committee that there is scientific Fluoride in Drinking Water: A
evidence that under certain conditions Scientific Review of EPA’s
fluoride can weaken bone and increase Standards. The National
the risk of fractures.” Academies Press: Washington,
D.C. 2006.
Fluoride in “The recommended Maximum Carton RJ. Review of the 2006

drinking water Contaminant Level Goal (MCLG) for United States National Research
fluoride in drinking water should be Council Report: Fluoride in
zero.” Drinking Water. Fluoride. 2006
Jul 1;39(3):163-72.
Fluoride in “Because the use of fluoridated dental Tiemann M. Fluoride in drinking

dental products, products and the consumption of food water: a review of fluoridation
food, and and beverages made with fluoridated and regulation issues. BiblioGov.
drinking water water have increased since HHS 2013 Apr 5. Congressional
recommended optimal levels for Research Service Report for
fluoridation, many people now may be Congress.
exposed to more fluoride than had been
anticipated.”
Fluoride intake “The ‘optimal’ intake of fluoride has Warren JJ, Levy SM, Broffitt B,
in children been widely accepted for decades as Cavanaugh JE, Kanellis MJ,
between 0.05 and 0.07 mg fluoride per Weber‐Gasparoni K.
kilogram of body weight but is based Considerations on optimal
on limited scientific evidence.” fluoride intake using dental
fluorosis and dental caries
“These findings suggest that achieving outcomes–a longitudinal study.
a caries-free status may have relatively Journal of Public Health
little to do with fluoride intake, while Dentistry. 2009 Mar
fluorosis is clearly more dependent on 1;69(2):111-5.
fluoride intake.”

Review of safety “If we were to consider only fluoride’s Prystupa J. Fluorine—a current
standards for affinity for calcium, we would literature review. An NRC and
exposure to understand fluoride’s far-reaching ATSDR based review of safety
fluorine and ability to cause damage to cells, organs, standards for exposure to
fluorides glands, and tissues.” fluorine and fluorides.
Toxicology Mechanisms and
Methods. 2011 Feb 1;21(2):103-
70.
Section 7.3: Lack of Ethics
Another major concern about fluoride exposure from drinking water and food is related to the production of the
fluorides used in community water supplies. According to the Centers for Disease Control and Prevention
(CDC), three types of fluoride are generally used for community water fluoridation:
• Fluorosilicic acid: a water-based solution used by most water systems in the United States.
Fluorosilicic acid is also referred to as hydrofluorosilicate, FSA, or HFS.
• Sodium fluorosilicate: a dry additive, dissolved into a solution before being added to water.
• Sodium fluoride: a dry additive, typically used in small water systems, dissolved into a solution
before being added to water.200
Controversy has arisen over the industrial ties to these ingredients. The CDC has explained that phosphorite
rock is heated with sulfuric acid to create 95% of the fluorosilicic acid used in water fluoridation. 201 The CDC
has further explained: “Because the supply of fluoride products is related to phosphate fertilizer production,
fluoride product production can also fluctuate depending on factors such as unfavorable foreign exchange rates
and export sales of fertilizer.”202 A government document from Australia has more openly stated that
hydrofluosilicic acid, sodium silicofluoride and sodium fluoride are all “commonly sourced from phosphate
fertilizer manufacturers.”203 Safety advocates for fluoride exposures have questioned if such industrial ties are
ethical and if the industrial connection to these chemicals might result in a cover-up of the health effects caused
by fluoride exposures.
A specific ethical issue that arises with such industry involvement is that profit-driven groups seem to define the
evolving requirements of what constitutes the “best” evidence-based research, and in the meantime, unbiased
science becomes difficult to fund, produce, publish, and publicize. This is because funding a large-scale study
can be very expensive, but industrial-based entities can easily afford to support their own researchers. They can
also afford to spend time examining different ways of reporting the data (such as leaving out certain statistics to
obtain a more favorable result), and they can further afford to publicize any aspect of the research that supports
their activities. Unfortunately, history has shown that corporate entities can even afford to harass independent
scientists as a means of ending their work if that work shows harm generated by industrial pollutants and
contaminants.
Indeed, this scenario of unbalanced science has been recognized in fluoride research. Authors of a review
published in the Scientific World Journal in 2014 elaborated: “Although artificial fluoridation of water supplies
has been a controversial public health strategy since its introduction, researchers—whom include internationally
respected scientists and academics—have consistently found it difficult to publish critical articles of community
water fluoridation in scholarly dental and public health journals.” 204

In relation to the ethics of medical and dental practices, a cornerstone of public health policy known as the
precautionary principle must be considered as well. The basic premise of this policy is built upon the centuries-
old medical oath to “first, do no harm.” Yet, the modern application of the precautionary principle is actually
supported by an international agreement.
In January 1998, at an international conference involving scientists, lawyers, policy makers, and
environmentalists from the U.S., Canada and Europe, a formalized statement was signed and became known as
the “Wingspread Statement on the Precautionary Principle.”205 In it, the following advice is given: “When an
activity raises threats of harm to human health or the environment, precautionary measures should be taken
even if some cause and effect relationships are not fully established scientifically. In this context the proponent
of an activity, rather than the public, should bear the burden of proof.” 206
Not surprisingly, the need for the appropriate application of the precautionary principle has been associated with
fluoride usage. Authors of a 2006 article entitled “What Does the Precautionary Principle Mean for Evidence-
Based Dentistry?” suggested the need to account for cumulative exposures from all fluoride sources and
population variability, while also stating that consumers can reach “optimal” fluoridation levels without ever
drinking fluoridated water.207 Additionally, researchers of a review published in 2014 addressed the obligation
for the precautionary principle to be applied to fluoride usage, and they took this concept one step further when
they suggested that our modern-day understanding of dental caries “diminishes any major future role for
fluoride in caries prevention.”208
Section 8: Conclusion
Based upon the elevated number of fluoride sources and the increased rates of fluoride intake in the American
population, which have risen substantially since water fluoridation began in the 1940’s, lowering exposures to
fluoride has become a necessary and viable alternative. For example, the author of a 2013 Congressional
Report noted that significant levels of fluoride can be obtained from sources other than water. 209 As another
example, researchers from the University of Kent in Canterbury, England, considered the quantity of fluoride
sources and wrote in 2014 that “the prime public health priority in relation to fluoride is how to reduce ingestion
from multiple sources, rather than adding this abundant and toxic chemical to water or food.”210
The sources of human exposure to fluoride have drastically increased since community water fluoridation began
in the U.S. in the 1940’s. In addition to water, these sources now include food, air, soil, pesticides, fertilizers,
dental products used at home and in the dental office (some of which are implanted in the human body),
pharmaceutical drugs, cookware, clothing, carpeting, and an array of other consumer items used on a regular
basis. Official regulations and recommendations on fluoride use, many of which are not enforced, have been
based on limited research and have only been updated after evidence of harm has been produced and reported.
Exposure to fluoride is suspected of impacting every part of the human body, including the cardiovascular,
central nervous, digestive, endocrine, immune, integumentary, renal, respiratory, and skeletal systems.
Susceptible subpopulations, such as infants, children, and individuals with diabetes or renal problems, are
known to be more severely impacted by intake of fluoride. Accurate fluoride exposure levels to consumers are
unavailable; however, estimated exposure levels suggest that millions of people are at risk of experiencing the
harmful effects of fluoride and even toxicity, the first visible sign of which is dental fluorosis. A lack of
efficacy, lack of evidence, and lack of ethics are apparent in the current status quo of fluoride usage.
Informed consumer consent is needed for all uses of fluoride, and this pertains to water fluoridation, as well as
all dental-based products, whether administered at home or in the dental office. Providing education about
fluoride risks and fluoride toxicity to medical and dental professionals, medical and dental students, consumers,
and policy makers is crucial to improving the future of public health.

There are fluoride-free strategies in which to prevent dental caries. Given the current levels of exposure,
policies should reduce and work toward eliminating avoidable sources of fluoride, including water
fluoridation, fluoride-containing dental materials, and other fluoridated products, as means to promote
dental and overall health.
This document consists of excerpts taken from the document entitled “International Academy of Oral Medicine
and Toxicology (IAOMT) Position Paper against Fluoride Use in Water, Dental Materials, and Other Products
for Dental and Medical Practitioners, Dental and Medical Students, Consumers, and Policy Makers.”
Click here to access the full document.
Endnotes:
1
National Research Council. Health Effects of Ingested Fluoride. The National Academy Press: Washington, D.C. 1993. p. 30.
And European Commission. Critical review of any new evidence on the hazard profile, health effects, and human exposure to fluoride and the
fluoridating agents of drinking water. Scientific Committee on Health and Environmental Risks (SCHER). 2011.
See more in Connett M. Fluoride is not an essential ingredient [Internet]. Fluoride Action Network. August 2012. Online at
http://fluoridealert.org/studies/essential-nutrient/. Accessed November 1, 2016.
2
See Table 2 on page 334 of Grandjean P, Landrigan PJ. Neurobehavioural effects of developmental toxicity. The Lancet Neurology. 2014
Mar 31;13(3):330-8.
3
National Research Council. Fluoride in Drinking Water: A Scientific Review of EPA’s Standards. The National Academies Press:
Washington, D.C. 2006. Page 52.
4
Prystupa J. Fluorine—a current literature review. An NRC and ATSDR based review of safety standards for exposure to fluorine and
fluorides. Toxicology mechanisms and methods. 2011 Feb 1;21(2):103-70. Page 104.
5
NobelPrize.Org. Henry Moissan facts [Internet]. Online at https://www.nobelprize.org/nobel_prizes/chemistry/laureates/1906/moissan-
facts.html. Accessed November 2, 2016.
6
Prystupa J. Fluorine—a current literature review. An NRC and ATSDR based review of safety standards for exposure to fluorine and
fluorides. Toxicology mechanisms and methods. 2011 Feb 1;21(2):103-70. Page 104.
7
http://pubs.acs.org/doi/pdf/10.1021/ac60086a019
8
Mullenix PJ. Fluoride poisoning: a puzzle with hidden pieces. International Journal of Occupational and Environmental Health. 2005 Oct
1;11(4):404-14. Pages 405.
9
Mullenix PJ. Fluoride poisoning: a puzzle with hidden pieces. International Journal of Occupational and Environmental Health. 2005 Oct
1;11(4):404-14. Page 404.
10
See, e.g., Riordan PJ. The place of fluoride supplements in caries prevention today. Australian
Dental Journal 1996;41(5):335-42, at 335 (“Around the same time (late 1940s), fluoride supplements seem to have been marketed in the US.
Fluoride supplements were being distributed regularly in US non-fluoridated areas in the early 1960s.”), attached as Exhibit 9; Szpunar SM,
Burt BA. Evaluation of appropriate use of dietary fluoride supplements in the US. Community Dentistry & Oral Epidemiology
1992;20(3):148-54, at 148 (“There is no firm documentation on when [fluoride supplements] first came onto the market, but it seems to have
been in the mid-to-late 1940s.”), attached as Exhibit 10.
In Connett M. Citizen petition to FDA re: fluoride drops, tables, & lozenges. May 16, 2016. To the United States Food and Drug
Administration (FDA) from the Fluoride Action Network (FAN) and the International Academy of Oral Medicine and Toxicology (IAOMT).
Online at http://fluoridealert.org/wp-content/uploads/citizens_petition_supplements.pdf. Accessed November 2, 2016.
11
McKay FS. Mottled Enamel: The Prevention of Its Further Production Through a Change of the Water Supply at Oakley, IDA. Journal of
the American Dental Association. 1933 Jul 1;20(7):1137-49.
12
Dean HT, McKay FS. Production of Mottled Enamel Halted by a Change in Common Water Supply. American Journal of Public Health
and the Nations Health. 1939 Jun;29(6):590-6. Online at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1529429/pdf/amjphnation00995-
0008.pdf. Accessed November 2, 2016.
13
Dean HT, Elvove E. Further studies on the minimal threshold of chronic endemic dental fluorosis. Public Health Reports (1896-1970).
1937 Sep 10:1249-64.
14
Dean HT, Arnold FA, Elvove E. Domestic water and dental caries. Public Health Rep. 1942 Aug 7;57(32):1155-79. Online at
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1968063/pdf/pubhealthreporig01481-0001.pdf. Accessed November 2, 2016.
15
Editorial Department (Anthony LP, editor). Effect of Fluorine on Dental Caries. Journal of the American Dental Association. 1944;
31:1360-1363.
16
Lennon MA. One in a million: the first community trial of water fluoridation. Bulletin of the World Health Organization. 2006
Sep;84(9):759-60. Online at http://www.scielosp.org/scielo.php?pid=S0042-96862006000900020&script=sci_arttext. Accessed November
2, 2016.
17
See page 105-7 in Prystupa J. Fluorine—a current literature review. An NRC and ATSDR based review of safety standards for exposure to
fluorine and fluorides. Toxicology mechanisms and methods. 2011 Feb 1;21(2):103-70.
18
Lennon MA. One in a million: the first community trial of water fluoridation. Bulletin of the World Health Organization. 2006
Sep;84(9):759-60. Online at http://www.scielosp.org/scielo.php?pid=S0042-96862006000900020&script=sci_arttext. Accessed November
2, 2016.
19
For a list of European countries that do not fluoridate drinking water and more information, see Fluoride Action Network. Statements
from European health, water, & environment authorities on water fluoridation [Internet]. 2007. Online at
http://fluoridealert.org/content/europe-statements/. Accessed November 2, 2016.
20
Centers for Disease Control and Prevention. Water fluoridation: fluoride statistics: 2014 [Internet]. Page last reviewed and updated
August 19, 2016. Online at http://www.cdc.gov/fluoridation/statistics/2012stats.htm. Accessed November 2, 2016.
21
United States Food and Drug Administration. August 5: Does the FDA regulate the use of fluoride in drinking water? Does a municipality
which is adding fluoride to the drinking water need any special application, exemption or waiver to carry out the process of fluoridation in a
drinking water system? [Internet]. Page last updated 2/19/2016. Online at http://www.fda.gov/drugs/newsevents/ucm363789.htm. Accessed
November 2, 2016.
22
See also Fluoride Action Network. Mandatory fluoridation in the U.S. [Internet]. Updated 2015. Online at
http://fluoridealert.org/content/mandatory-fluoridation-in-the-u-s/. Accessed November 2, 2016.
23
Peckham S, Awofeso N. Water fluoridation: a critical review of the physiological effects of ingested fluoride as a public health
intervention. The Scientific World Journal. 2014 Feb 26;2014. Online at http://downloads.hindawi.com/journals/tswj/2014/293019.pdf.
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24
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Additional studies finding reduced IQ in communities with less than 4 mg/L have become available in the years since Choi’s review,
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210

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International Academy of Oral Medicine and Toxicology (IAOMT)

Comprehensive Review on Artificial Water Fluoridation

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 1

Table 1: Examples of Products that May Contain Added Fluoride

Section 2: Sources of Fluoride in Water

Section 3: Brief History of Artificial Water Fluoridation

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 2

Section 4: Overview of U.S. Artificial Water Fluoridation Regulations

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 3

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 4

Section 5.1: Skeletal System

Figure 1: Dental Fluorosis Ranging

Section 5.1.2: Skeletal Fluorosis and Arthritis

Section 5.1.3: Cancer of the Bone, Osteosarcoma

Section 5.2: Central Nervous System

Section 5.3: Cardiovascular System

Section 5.4: Endocrine System

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 7

Section 5.5: Renal System

Section 5.6: Respiratory System

Section 5.7: Digestive System

Section 5.8: Immune System

Section 5.9: Integumentary System

Section 6: Fluoride Exposure Levels

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 10

Section 6.1: Individualized Responses and Susceptible Subgroups

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 12

Section 6.3: Interactions of Fluoride with Other Chemicals

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 13

Section 7.1: Lack of Efficacy

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 14

Fluoride in “Overall, there was consensus among National Research Council.

Fluoride in “The recommended Maximum Carton RJ. Review of the 2006

Fluoride in “Because the use of fluoridated dental Tiemann M. Fluoride in drinking

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 16

Section 7.3: Lack of Ethics

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 17

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 18

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 21

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 25

International Academy of Oral Medicine and Toxicology (IAOMT) www.iaomt.org; Page 30

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